What is the appropriate workup and treatment for a patient presenting with urge incontinence?

Workup for Urge Incontinence

Begin with a focused history documenting urgency (sudden compelling desire to void that is difficult to defer), frequency, nocturia, and urgency incontinence episodes, followed by physical examination, urinalysis, and consideration of a voiding diary—this constitutes the minimum diagnostic workup required before initiating treatment. 1

Essential Initial Evaluation

History Components

• Document the hallmark symptom of urgency: the sudden, compelling desire to pass urine which is difficult to defer 1
• Quantify urinary frequency: traditionally up to 7 micturitions during waking hours is considered normal, though this varies with sleep hours, fluid intake, and comorbidities 1
• Assess nocturia: interruption of sleep one or more times to void, recognizing this is multifactorial and may be unrelated to overactive bladder (consider nocturnal polyuria, sleep apnea) 1
• Characterize incontinence episodes: determine if leakage is associated with urgency (urgency incontinence) versus physical stress (stress incontinence) to differentiate mixed incontinence 1
• Evaluate symptom duration and baseline severity: ensure symptoms are not related to other conditions and determine if referral is needed 1
• Review current medications: many drugs can cause or worsen urinary symptoms 1
• Screen for neurologic diseases and genitourinary conditions: these directly impact bladder function and may require specialist referral 1
• Assess degree of bother: if the patient is not significantly bothered, there is less compelling reason to treat 1

Physical Examination

• Perform abdominal examination: assess for masses, distension, or suprapubic tenderness 1
• Conduct rectal/genitourinary examination: evaluate for pelvic organ prolapse, pelvic masses, or anatomic abnormalities 1
• Assess lower extremities for edema: may indicate fluid redistribution contributing to nocturia 1
• Evaluate cognitive function: cognitive impairment relates to symptom severity and has therapeutic implications regarding treatment goals and options 1
• Assess functional status: the ability to dress independently is informative of sufficient motor skills related to toileting habits 1

Mandatory Laboratory Testing

• Urinalysis to rule out UTI and hematuria: if hematuria not associated with infection is found, refer for urologic evaluation 1

Optional Additional Testing (At Clinician's Discretion)

Voiding Diary

• Consider a bladder diary: reliably measures frequency, volume per void, and incontinence episodes over multiple days 1, 2
• Useful for documenting baseline symptom levels: provides objective data for treatment monitoring 1

Post-Void Residual (PVR)

• May perform PVR assessment: helps identify urinary retention or incomplete bladder emptying 1, 2
• Particularly important in patients with neurologic conditions: relevant neurological disorders predisposing to upper tract complications require PVR as part of initial and ongoing evaluation 1

Urine Culture

• Consider urine culture if UTI suspected: particularly if urinalysis shows pyuria or patient has recurrent infections 1

Symptom Questionnaires

• Validated questionnaires can aid diagnosis: provide standardized assessment of symptom severity and quality of life impact 1, 2

When to Consider Advanced Testing

Urodynamic Studies (UDS)

• May perform multichannel filling cystometry when invasive, potentially morbid, or irreversible treatments are considered: helps determine if altered compliance, detrusor overactivity, or other urodynamic abnormalities are present 1
• Consider UDS when conservative and drug therapies fail: patients desiring more invasive treatment options may benefit from urodynamic evaluation 1
• Useful in mixed incontinence: may aid in symptom correlation, though tests may not precisely predict treatment outcomes 1
• Important caveat: the absence of detrusor overactivity on a single urodynamic study does not exclude it as a causative agent for symptoms 1

Cystourethroscopy

• Perform prior to surgical intervention: assess for urethral and bladder pathology (stricture, bladder neck contracture, lesions) that may affect surgical outcomes 1

Common Pitfalls to Avoid

• Do not skip the voiding diary: objective documentation of frequency and incontinence episodes is far more reliable than patient recall 1
• Do not assume all nocturia is due to overactive bladder: nocturnal polyuria (large volume voids at night) suggests different pathophysiology requiring different management 1
• Do not overlook medication review: many commonly prescribed drugs (diuretics, antihypertensives, sedatives) can worsen urinary symptoms 1
• Do not proceed to invasive testing without adequate trial of conservative management: urodynamics and cystoscopy are reserved for refractory cases or when considering surgical intervention 1
• Do not confuse stress and urgency incontinence: in mixed incontinence, it can be difficult to distinguish subtypes, but treatment approaches differ significantly 1, 3

When to Refer

• Refer patients with neurologic diseases: these conditions directly impact bladder function and require specialist evaluation 1
• Refer if hematuria is present without infection: requires urologic evaluation to exclude malignancy 1
• Consider referral for complex cases: patients with prior pelvic surgery, radiation, or anatomic abnormalities may benefit from specialist management 1